Journal of the New Zealand Medical Association, 20-February-2004, Vol 117 No 1189
Concerns of health providers and parents affect immunisation coverage
New Zealand has a disappointing record with immunisation coverage as we continue to languish with low immunisation rates, well below the targets set in earlier national strategies.1 While there are currently no available national coverage data, the high background rates of pertussis disease alone suggest that coverage rates are unlikely to have improved much over the 1992 national coverage survey. This survey showed that less than 60% of children, and more alarmingly only 42% of Maori and 45% of Pacific children, were fully immunised by two years of age.2
Despite the disappointing national picture, local initiatives have shown it is possible to achieve and maintain higher coverage rates, such as those seen in Rotorua. These all take local flavour, but show the key characteristics of committed teams and integrated processes at the primary healthcare level.
The international literature reflects several clear themes on how to gain and maintain high immunisation coverage. These cover enhancing access and provider-based interventions and strategies to increase community demand.3 Key aspects of delivery include financing the system effectively, focussing on provider practice, appropriate integrated information systems and community support.3
Possibly of greatest importance in the overall picture in obtaining high immunisation coverage is the role of the primary care providers – both their support and knowledge base appear to be vital ingredients for improving immunisation rates – and this may be a more important aspect than parental knowledge base.4
The excellent paper in this edition by Jelleyman and Ure demonstrates that health professionals in the Rotorua District express strong statements of support for immunisation, but hold significant underlying uncertainties.5 Of note is that 11% of health professionals consider immunisation to have unacceptable dangers and a further 17% are unsure. Furthermore, over one third of health professionals were uncertain about the lack of association between autism and MMR. There is a well-established and vast scientific literature around immunisation risks and dangers and the particular issue of MMR/autism has been broadly discredited, 6 although continues to have a life through the media. The knowledge base and attitudes of health professionals do not appear to match their belief in the importance of science, and how little they consider themselves to be influenced by the media. This highlights the need for us as health professionals to be more discerning and to look more critically at our knowledge gaps and the influences building our attitudes.
Recent research in New Zealand looking at general practitioner knowledge and attitudes nationally has highlighted both significant knowledge gaps and the desire of health professionals for extra resources to support more effective communication with parents.7 In this research, health professionals failed to recognise the importance of their own knowledge gaps and educational needs. The most significant barrier to raising coverage identified by GPs was parental concerns over vaccine safety and associated misconceptions. The second most significant barrier was the concern over lack of funding to providers. This is strongly backed by the international literature, which shows clear relationships between improved coverage and financial and quality support to health professionals. The inadequacy of the immunisation benefit subsidy, particularly to cover the costs of children who are harder to access, has been frequently highlighted.8
The antenatal period also needs focus as an important ingredient. New Zealand research has shown that the majority of mothers make their decision around immunisation in the antenatal period.9 Furthermore, it has been shown that parents lack information in this period and wish to have more.9 Jelleyman and Ure support this concern by showing the significant knowledge gaps and range of attitudes displayed by some antenatal providers. Will extra focus in this area make a difference? An interesting New Zealand study from 2001 (A Wroe, N Turner, unpublished data) demonstrated that giving increased information in the antenatal period with a decision-making aid does follow through to a significant increase in timely immunisation coverage in the infant.
The paper by Hamilton et al delineates the common themes from parents who chose not to vaccinate.10 While there are no precise data, information to date suggests the anti-immunisation lobby to be in the order of 5–6% of the population.11,12 This group has always been an active part of the New Zealand scene. The importance of this sector is not so much its existence, as its members remain a small percentage of the community, as its influence on the wider community, particularly as modern communication tools such as the Internet create much more effective and rapid access to wide networks. Local research has already demonstrated that there is a high level of misconception about the issues surrounding immunisation, with one in eight mothers not believing that vaccines are effective and a staggering one in five mothers (one in three of those under 24 years) believing that good hygiene and nutrition will prevent the diseases vaccinated against.11
It is hardly surprising that the most consistent message coming through from parental and health professional research is that one of the biggest barriers to achieving immunisation in New Zealand is parental fear.7,13 This is also reflected in parents in the Maori community.13 The parents of our most vulnerable children frequently have considerable logistic, financial and, at times, cultural barriers to overcome to complete an immunisation event. It does not take much to seed a degree of doubt or fear in a struggling parent to make the likelihood of achieving a full and timely course of immunisation even more remote.
Current strategy in New Zealand is appropriately being directed towards being able to track and offer services to the children who are missing out. However, until we also seriously tackle the considerable gaps in the needs of health professionals – both resource needs and knowledge gaps – we are unlikely to make much headway with addressing community-wide fears and misconceptions around immunisation and attitudes.
As New Zealand children, particularly Maori and Pacific, continue to suffer the terrible burden of meningococcal B disease the new MeNZB® vaccine is in the last phases of trials. Current data are looking positive and, if the trials continue to a successful completion, New Zealand can hope to see this vaccine introduced to all children under 20, progressively around the country from mid-2004 onwards. This is a very ambitious programme, but the needs of our children are urgent. It will need strong support to reach the most vulnerable. Health professional support and education and community communication strategies are core components.
Author information: Nikki Turner, Director Immunisation Advisory Centre, Department of General Practice and Primary Health Care, University of Auckland, Auckland
Correspondence: Dr Nikki Turner, PO Box 17360, Greenlane, Auckland. Fax: (09) 373 7030; email: email@example.com
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